=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447277322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA CARDIOVASCULAR INSTITUTE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2006
-----------------------------------------------------
Last Update Date | 11/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 S ARMENIA AVE STE. 200
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33609-3395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-353-1515
-----------------------------------------------------
Fax | 813-353-0485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 509 S ARMENIA AVE STE. 200
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33609-3395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-353-1515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN THOMPSON SULLEBARGER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 813-353-1515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------